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The Periodic Health Examination Provided to Asymptomatic Older Women: An Assessment Using Standardized Patients

Patricia A. Carney, RN, MS; Allen J. Dietrich, MD; Daniel H. Freeman, PhD; and Leila A. Mott, MS
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From the University of Washington, Seattle, Washington; Dartmouth Medical School, Hanover, New Hampshire; the University of Texas Medical Branch, Galveston, Texas. Requests for Reprints: Patricia A. Carney, RN, MS, Department of Community Health Care Systems, SM-24, School of Nursing, University of Washington, Seattle, WA 98195. Acknowledgments: The authors thank Maggie Moore-West, PhD, for her help in the conceptualization of this project; physicians of the Dartmouth Primary Care Cooperative Information Network who assisted with developing the standardized patient scenario; and Susanna Reed for manuscript preparation. Grant Support: Supported by grants CA46075, CA23108, and CA531521 from the National Cancer Institute.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(2):129-135. doi:10.7326/0003-4819-119-2-199307150-00007
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Objectives: To describe physical examination and cancer prevention services provided by primary care physicians in response to the request for a checkup by an asymptomatic 55-year-old woman seeking to establish ongoing care; to assess the effects of two interventions (education and office organization) intended to improve these services; and to assess the feasibility of using standardized patients to evaluate physician responses to such a request.

Setting: Northern New England.

Participants: Fifty-nine primary care physicians who were accepting new patients and were participating in a study of early detection and prevention of cancer.

Design: Cross sectional; observations of patient visits.

Interventions: Actresses trained to portray a specific patient role (standardized or simulated patients) visited each physician once. Physicians were blinded to the simulated patients' true identities.

Measurements: Actresses reported the components of the general physical examination and the cancer-related checkup. Most interactions were audiotaped.

Results: Fourteen physical examination components were measured, ranging from assessment of vibratory sense (5%) to measurement of blood pressure (98%). Provision of 10 services recommended by the National Cancer Institute to standardized patients included 16% being advised to reduce dietary fat; 53% to do monthly breast self-examination; 74% to quit smoking; and 89% to obtain a mammogram. Physicians spent from 5 to 60 minutes with the patients. Two physicians did not charge, whereas others charged from $24 to $108. Study group assignment was not associated with statistical differences in provider performance. Two standardized patients (3%) were detected by physicians. Audiotapes were used to verify the actresses' ability to replicate their scenario (consistently repeat their performance) and to verify physician performance.

Conclusions: Physician responses to an identical patient request varied widely in terms of time spent with the patient, the services provided, and the cost of the visit. Using standardized patients is a feasible method for assessing physician performance of the periodic health examination while controlling for case mix.


Grahic Jump Location
Figure 1.
Percentage of physicians (n = 57) providing various components of the physical examination.
Grahic Jump Location
Grahic Jump Location
Figure 2.
Percentage of physicians (n = 57) providing selected preventive recommendations.

Pap = Papanicolaou.

Grahic Jump Location




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